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Psychology & Neuroscience, 2014, 7, 4, 453-460


DOI: 10.3922/j.psns.2014.4.04

Executive function in children with ADHD


Janna M. Glozman1 and Irina A. Shevchenko2
1- Lomonosov Moscow State University, Moscow, Russia
2- Luria Research Centre of Developmental Neuropsychology, Moscow, Russia

Abstract
The study of executive function was one of the main topics of the work of A.R. Luria. Attention-deficit/hyperactivity disorder
(ADHD) presents a good model of executive disorders, the experimental study of which reveals a complex structure of executive
behavior including sustaining activity and attention, selectivity in decision making, shifting, planning, and prognostic ability.
Cross-cultural (Russian/Italian) differences in executive function in children with ADHD are discussed. Comparisons of
ADHD in preschool and primary school children are made in an attempt to prevent the aggravation of deficits and provide early
remediation. Keywords: A. R. Luria, neuropsychology, executive function, ADHD, preschool age.

Received 01 March 2014; received in revised form 22 July 2014; accepted 25 July 2014. Available online 16 December 2014.

The problem abilities that are involved in the control and coordination
Lurias concept of three functional units (blocks) of the of information in the service of goal-directed actions and
brain (Luria, 1973) permits an understanding of the many has been studied in the cognitive development literature
problems associated with abnormal child development. (Willoughby, Wirth, & Blair, 2012).
The last unit that is maturated is the brain, providing the The underdevelopment of executive function lies
control and voluntary regulation of activities, later called at the core of most dysontogenesis syndromes, greatly
executive function. The voluntary regulation of mental influencing a childs behavior and learning in preschool
activity includes the following: (i) an objective setting, in and school (Kovalchikova, 2014).
accordance with motivation and the purpose of actual or
planned activity, (ii) planning a program and the best ways A disobedient child rarely deviates from the given
to achieve a goal, (iii) monitoring the implementation of instructions by unwillingness to follow them.
the program and the timely correction of inadequate actions He cant just yet and doesnt know how to keep
and associations, and (iv) comparisons of objectives with himself from an action unapproved by adults. Too
intermediate and final results. large is his dependence on direct influences of the
After the work of Luria, many studies evaluated the outside world; still very difficult is to predict the
structure of executive function and their relationships results of own actions, to divide in own mind the
with cognitive function (Wilkins, Shallice, & McCarthy, desired now and the possible after (Korsakova,
1987; Nigg, 2005; Willcutt, Doyle, Nigg, Faraone, & Mikadze, & Balashova, 2001, p. 32).
Pennington, 2005; Diamond, 2013). Broadly defined,
executive function refers to a complex set of cognitive The long process of maturation of the unit of
abilities that underlie adaptive, goal-directed behaviors activity programming and monitoring, according to
and enable individuals to override more automatic or psychophysiologists, has several critical points. Above
established thoughts and responses (Garon, Bryson, & all, the crucial period is between 6 and 7 years of age
Smith, 2008; Diamond, 2013). At a more fine-grained when, according to electroencephalography data, a
level, a set of cognitive control skills (e.g., attention, simple emotional brain activation system is replaced
inhibitory control, self-monitoring, and flexibility) is by the verbal voluntary control of the brain with the
defined as specific interrelated information-processing growing participation of the frontal lobes of the left
hemisphere (Adrianov & Farber, 1990). During this
critical period, the childs schooling begins. Unsurprising
Janna M. Glozman, Lomonosov Moscow State University, is that all executive functions, including programming
Moscow, Russia. Irina A. Shevchenko, Luria Research
and monitoring individual actions, forming designs
Centre of Developmental Neuropsychology, Moscow, Russia.
Correspondence regarding this article should be directed to: and purposes of activities, and regulating behavior, are
Janna M. Glozman, Moscow State University - Psychology, deficient in children with learning problems.
11 Mohovaya St., b.5 , Moscow 125009, Russian Federation. Attention-deficit/hyperactivity disorder (ADHD)
E-mail: Glozman@mail.ru is one of the most common behavioral and learning
454 Glozman and Shevchenko

disorders among children and a frequent reason for analyze cross-cultural differences in performance on
seeking psychological help in childhood (Barkley, 1998; these tests.
Nigg, 2005). According to the criteria of the Diagnostic
and Statistical Manual of Mental Disorders, 4th edition, Methods
text revision (DSM-IV-TR; American Psychiatric The present experiment used the Shulte test from the
Association, 2000), the frequency of ADHD varies Luria battery (Luria, 1973) and a test of figure matching.
from 3 to 20% (Romanchuk, 2010), and the official Both of these instruments measure the sustaining of
indicator in the DSM-IV is 3-5% (American Psychiatric activity and attention. The Hayling Sentence Completion
Association, 2000). This means that one in 30 children Test (Shallice, Marzocchi, Coser, del Savio, Meuter, &
has ADHD, suggesting that each class in primary school Rumiati, 2002) and an analogous test from the Luria battery
has at least one student with ADHD. measure selectivity in decision making. Dynamic praxis, a
At the behavioral level, this disorder is primarily test of conventional reactions from the Luria battery, and
manifested by excessive and unjustified physical the Numeric Stroop test (Marzocchi, Re, & Cornoldi,
activity, fussiness, and impulsivity that exceed the 2010) measure shifting. The problem-solving test and
limits of age standards, in addition to difficulties Everyday Planning Test (Marzocchi et al., 2010) measure
concentrating attention because of frequent switches the planning of steps and coherence between planning
in attention. Neuropsychological assessment identifies and execution. The Junior Iowa Gambling Task (Bechara,
in these children the immaturity of various cognitive Damasio, Damasio, & Anderson, 1994) measures the
functions, including gnosis, orientation in space, and ability to compare gains and loses and recall performance.
problem solving, among others (Glozman, Kurdukova, The Conners Scale determines the level of ADHD (Passolt,
& Chibisova, 2007; Glozman, Kurdyukova, & 2004). Let us provide some details on some of the tests
Shevchenko, 2013; Kurdyukova, Glozman, & Chibisova from the Italian battery for executive function.
2010; Glozman, 2013).
The disorder typically occurs early in the development Instruments
process, usually within the first 5 years of life. However,
Hayling Sentence Completion Test. In this test,
the peak of referrals to specialists occurs by 6 or 7 years
children must finish orally presented sentences with a
of age when excessive, poorly organized, and poorly
missing final word that is semantically related (Part A)
regulated activity becomes an obstacle to intensive
or completely unrelated (Part B) to the sentence. The
training activities. Even with relatively high intellectual
missing words are matched for frequency and age of
potential, children with ADHD are often unsuccessful
acquisition. Each type of answer (i.e., answers that meet
at school and experience difficulties adapting socially to
or do not meet the requirements) are scored. High scores
peers (Pennington et al., 1993; Osipova & Pankratova,
on Part B reveal a lack of selectivity.
1997).
Numeric Stroop. In this test, children are required to
Unfortunately, despite the frequency of the syndrome,
count numbers. The trials are divided into two sessions. The
this disorder is often diagnosed late or incorrectly or
baseline session has 12 stimuli (stars), and the experimental
not detected at all. The behavior of the child can be
sessions have 75 groups of identical numbers. The number
explained by a lack of diligent upbringing by the parents
of naming errors in which the child names numbers instead
or bad character of the child, which cannot be changed.
of counting them is recorded, in addition to the difference
Accordingly, most children do not receive timely and
in time to count stars and count numbers (i.e., Interference
necessary support. The variety of methods for ADHD
Time) attributable to the Stroop effect.
assessment is substantial and differs between Russia and
Everyday Planning Task (EPT). This is a semi-
Western countries. Therefore, finding converging points
ecological task that has two versions: a version for
and a theoretical foundation of the most frequently used
children between 8 and 10 years of age and a version
tests is very important.
for children between 11 and 14 years of age. The
instrument includes three different tasks: memory
EXPERIMENTAL STUDY: PART I task, time estimation task, and planning task. In the
The first part of our experimental study sought memory task, the children must recall activities (e.g.,
to select sensitive methods to reveal mechanisms of buying bread for grandmother, going to training, and
executive disorders in children with ADHD through doing homework) listed by the examiner in any order.
an international study (Glozman, Marzocchi, & In the time estimation task, the children must estimate
Kurdukova, 2012) by doing the following: (i) compare the duration of each activity. In the planning task, the
the discriminative value of some Lurian and Western tests children must order 10 activities according to logical
for ADHD diagnosis with regard to executive function and chronological constraints in a maximum of 30 min.
in learning-disabled primary school students, (ii) reveal The children can see the list of 10 activities, and they
the potential of these tests to describe the structure of have an answer sheet and map of the city where these
executive behavior, including sustaining attention, activities are performed. The dependent variables are (i)
selectivity of attention, shifting in execution, planning, the recall of activities in the memory task, (ii) the correct
recalling of performance, and error correction, and (iii) planning of activities (relationship between properly
Executive function in ADHD 455

planned activities and number of moves required to and endogenic disease) that interferes with learning
complete them) in the planning task, (iii) number of in a public school. Both samples were diagnosed with
rule violations, (iv) coherence (consistency between ADHD according to the criteria of the International
estimation and effective use of time in the planning Statistical Classification of Diseases and Related
task), and (v) time to execute the task. Health Problems, 10th revision (ICD-10; World Health
Junior Iowa Gambling Task. In this task, the Organization, 2009), using a semi-structured interview
subjects are presented with four virtual decks of cards with the parents. The ADHD diagnosis was confirmed by
on a computer screen. They are told that each time they the Conners Questionnaire for parents (Conners T score
choose a card they can win some game money (a reward). = 70). The cut-off was established as T 70. The parents
However, choosing some of the cards often causes them provided written informed consent for assessment. Both
to lose some money (a penalty). The goal of the game is groups were matched by age (Table 1).
to win as much money as possible. The decks differ from
each other in the way that the losses are distributed. Thus, Results
some decks are bad decks, and other decks are good On the Italian Executive Function battery, Italian
decks, in which some cards will lead to losses over the children showed poorer performance than Russian
long run, and others will lead to gains. The dependent children on coherence to use time in the EPT, and they
variable is the gain or loss of money at the end of 100 were faster (probably more impulsive) than the Russian
cards. The Iowa Gambling Task copies daily, real-life children. Russian children produced more errors in the
decisions (Damasio, 1994) and has provided a strong Numeric Stroop task. Italian children did not present
impetus to understand the role of the emotional system in comorbid learning disorders; therefore, the absence
the organization of decision-making behavior (Bechara, of comorbidity could justify their better performance
2005; de Visser et al., 2011; Glscher et al., 2012). compared with Russian children. We did not find
significant differences in the other measures of the EPT,
Subjects in interference time in the Numeric Stroop test or on the
Thirty-seven learning-disabled (inclusion criterion) Junior Iowa Gambling Task (Table 2).
public primary school students (19 Russian and 18 In the Russian executive function tasks, the two groups
Italian), 8-13 years old, were included in the study. did not show significant differences in the Analogies test,
The exclusion criteria were very low intellectual level but they performed significantly different on the Shulte test
(debility) or psychiatric pathology (e.g., depression and Test of Conventional Reactions (Table 3).

Table 1. Subjects of the international study of ADHD.

Measure Russian group Italian group t-test p


(14 male, 5 female) (16 male, 2 female)

Age 9.00 (1.00) 9.78 (1.70) 1.78 .097

Conners ADHD scale 74.79 (10.57) 78.11 (7.67) 1.87 .069

Table 2. Scores on the Italian battery of executive tests in children with ADHD.

Measure Russian group Italian group t-test p


(14 male, 5 female) (16 male, 2 female)

Everyday Planning Task

Memory 8.00 (1.53) 8.50 (1.20) 1.103 .278

Planning 0.96 (0.17) 1.05 (0.17) 1.735 .092

Violations 1.89 (2.31) 1.33 (1.19) .923 .363

Coherence 6.68 (1.42) 4.71 (2.63) 2.479 .021*

Time 14.99 (3.86) 12.47 (3.22) 2.148 .039*

Numeric Stroop

Errors 3.47 (2.23) 1.72 (1.36) 2.825 .008*

Interference time -.001 (.52) .27 (.31) 1.883 .068

Iowa Gambling Task

Money Gain or Loss -48.16 (77.45) -49.17 (74.07) .040 .968

*p < .05.
456 Glozman and Shevchenko

Table 3. Scores on the Russian battery of executive tests in children with ADHD.

Measure Russian group Italian group t-test p


(14 male, 5 female) (16 male, 2 female)

Shulte Test 1.55 (.78) .67 (.71) 3.614 .001*

Test of Conventional .95 (.43) .56 (.51) 2.529 .016*


Reactions

Analogies Test .40 (.44) .17 (.38) 1.701 .098

*p < .05.

Therefore, the results of this first part of the study in learning and behavior caused by underdevelopment
showed that the differences between children with or individual peculiarities of the functioning of brain
and without ADHD were reflected by worse scores structures (Glozman, 2013). The early development of
on all of the tests in the first group and qualitative the child was analyzed using a special questionnaire for
differences, including the lack of step planning, the lack parents.
of comparing ones own actions with previous results,
impulsivity, and difficulty recalling performance. The Subjects
most discriminative instruments for groups with and Nine preschool children with ADHD confirmed by a
without ADHD were the Numeric Stroop test and Test neurological assessment and the Conners Scale (Conners
of Conventional Reactions. Cross-cultural differences Scale-10 score > 15) participated in the study, with seven
were mostly seen in tasks that included time planning. boys and two girls aged 3-6 years. All nine preschoolers
The difference between the two groups (Russian and attended a course of neuropsychological remediation
Italian) tended to be significant on the Conners scale, at the Moscow Research Centre of Developmental
which may impact the difference in executive function Neuropsychology. A control neuropsychological follow-
between the two groups. up was done to reveal the dynamics of the results after
remediation.
EXPERIMENTAL STUDY: PART II In addition to this sample, 13 school children with
An analysis of the corresponding literature showed a diagnosis of ADHD were evaluated, confirmed by
that the observations in most studies were made for neurological assessment and Conners Scale-80 data,
children of school age. This is a period when the signs with 11 boys and two girls aged 7-11 years.
of ADHD are manifested more clearly. The mechanisms
of the development and manifestation of ADHD in Results
early and preschool age remain largely outside the To perform a comparative analysis of the
focus of psychologists. This is why neuropsychological neuropsychological data in preschool and school children
assessments of children with specific needs and deficits before remediation, we compared the data of the Lurian
in the development of mental function in preschool neuropsychological assessment before remediation
age are important for psychological and pedagogical between preschool and school children. School children
practice. An early diagnosis and remediation should without remediation during the preschool period
be oriented toward the preschool age when the showed minimal positive differences from preschoolers
compensatory abilities of the brain are greater and we in gnostic and mnestic functions that can be associated
are able to prevent persistent abnormal manifestations with the development of children, whereas the average
(Litsev, 1995; Osipenko, 1996; Haletskaya, 1999). This cumulative cognition scores remain unchanged.1
was the aim of our study. Many mental spheres were evaluated such as the
orientation of children in time and space their general
Methods knowledge, the control of their own behavior, critical
The Conners Scale was used to determine the level attitudes about mistakes made, and adequacy during
of ADHD (Passolt, 2004). This questionnaire contains assessment. An underdevelopment of verbal function
either 10 questions (short version) or 80 questions (full was revealed, including expressive speech, naming,
version) that assess behavior in children. In this study, and understanding logical and grammatical structures.
the parents of preschoolers were given the short version However, the most negative changes were observed
of the questionnaire, whereas parents of primary school in neurodynamic functions. For various reasons, the
students completed the full version. level of functional brain activity in children is unstable,
The methods of Lurian neuropsychological has poor resistance to loads, and requires constant
examination were adapted to the child population, and the stimulation, with alternating periods of productive work
results were evaluated quantitatively and qualitatively.
These methods allowed us to differentiate difficulties 1
In the Lurian system, higher scores indicate worse abilities.
Executive function in ADHD 457

and rest. Therefore, the working capacity of students worse scores (without remediation) for neurodynamics,
worsens with ever-increasing loads of school work from memory, and the ability to solve problems.
year to year (Figure 1). Hyperactivity or excessive motor disinhibition
In addition to the quantitative analysis of scores is a manifestation of fatigue. A tired child, unlike an
on the neuropsychological assessments in both groups adult, cannot control the condition and needs time to
of children, we performed a comparative qualitative rest, manifested by overdrive and reflected by chaotic
analysis of deficits in higher mental function in subcortical excitation. Consequently, children exhibit
preschool and school children. The results are presented specific changes in neurodynamic nervous processes.
in Figure 2. One can see an increase in the number The mental process in children is also manifested
of deficits in the areas of speech, memory, and by apparent weakness in the formation of the unit of
neurodynamics among school children compared with brain activation. Defects in the neurodynamic bases
preschool children. of mental functions indicate that acquired information
Spearman rank correlation showed that the age of remains unstable and rapidly disappears (or is inhibited)
the child had a significant correlation with neurodynamic by interfering influences, especially homogeneous
indicators, memory impairment, and the ability to influences, even with sufficient memorization ability
solve problems. This means that older children have (Glozman, 2013).

Figure 1. Comparative pattern of neuropsychological assessment data in preschool and school children with ADHD before remediation.

Figure 2. Percentage of deficits in preschool and school children with ADHD.


458 Glozman and Shevchenko

Mathematical problem solving requires planning and


execution processes to achieve results. A hyperactivity
disorder involves the immaturity of planning, a lack of
control over ones own movements, and higher levels of
movement. This affects complex multi-level action such
as solving a mathematical problem, which causes great
difficulty for children with ADHD.
Let us now consider the factors that aggravate
cognitive underdevelopment in children with ADHD.
Recent studies revealed many factors that can lead to
the appearance of ADHD. This is why a multicausal
theory of the development of ADHD is predominant.
Biological factors, especially perinatal hypoxic lesions
of the central nervous system, are the most important
during the first 2 years of life. During later development,
Figure 3. Example of graphic test and drawings of a table made by an
the disorder also depends on psychological and social 11-year-old boy with ADHD.
factors such as the family situation, upbringing, and
financial and social conditions (Zavadenko, Petruhin, &
Solovev, 1997). The causes of the observed symptoms movements (e.g., crawling and gripping a toy) stimulate
were revealed in our study through an analysis of the the formation of constant object images and orientation in
data of the checklist of early child development. space. As mentioned above, spatial defects are observed
Significant correlations were found between in most children with ADHD and are aggravated in
children with ambidexterity and the severity of reasoning school age (Figure 3). Perseverations and uncoordinated
deficits, indicating the need for a specialized approach movements can be seen, together with difficulty following
to forming intellectual function in children with programs in dynamic praxis and the immaturity of spatial
incomplete dominance of the left hemisphere. Significant functions in praxis and drawing.
correlations were also found between birth pathology
and quantitative praxis scores. The more noticeable Remediation of ADHD
birth pathologies included cord entanglement, asphyxia, Even psychiatrists say that drugs alone do not
hypoxia, and hypotrophy, with significant impacts on solve the entire spectrum of problems associated with
motor coordination, fine motor skills, and praxis. ADHD because problems related to the development
Significant correlations were found between of higher mental functions cannot be overcome with
abnormal motor development during the first year of medications. The follow-up of children with ADHD
life and quantitative scores on preschoolers speech has shown the importance of a comprehensive strategy
development and speech defects. The study of children of motor and cognitive remediation of children with
with speech pathology showed that they have motor this syndrome.
development problems that begin at a very early age. The development of executive function, including
These children did not have any neurological motor voluntary regulation, orientation, and the control of ones
symptoms (e.g., hyperkinesias and paresis), but they own activities, is a central focus of the neuropsychological
began to maintain their head, sit, and stand later remediation of hyperactive children with attention
than age-related norms. They also formed locomotor deficits. Remediation methods are based on two main
functions later, including climbing, walking, and approaches: overcoming neurodynamic problems through
jumping. Psychomotor deficits in most children the saturation of the child by activity and use of external
with speech pathology suggest an interrelation support to mediate regulatory functions (Kurdyukova et
and interdependence between speech and motor al., 2010; Glozman, 2013; Glozman et al., 2013). The
development. They also indicate a functional unity scope of the present article does not permit a detailed
between speech (not only its motor component) and description of these methods.
motor systems during the process of forming a childs In the present study, all of the preschoolers
ontogenesis. The stimulation of finger movement has followed a course of neuropsychological remediation.
been shown to affect maturation of the central nervous At the end of the course, a control neuropsychological
system (Koltsova, 1973). follow-up was performed, showing positive dynamics
Speech deficits in children with motor (i.e., a reduction of penalty scores) in all spheres of the
underdevelopment indicate the importance of the motor childrens development. The most significant changes,
system in a childs neuromental development, proving based on Wilcoxon t-tests, were found in praxis (p =
the need for specialized complex neuropsychological .008), gnosis (p = .018), memory (p = .012), reasoning
remediation for all components of a childs motor (p = .018), and conditioned reactions (p = .043; Figure
development. 4). Additionally, significant improvements were
Significant correlations were found between childs observed in total neuropsychological scores (i.e., the
motor retardation and gnostic defects. Active hand average of all spheres of the childrens assessment).
Executive function in ADHD 459

Figure 4. Dynamics of scores of preschool children with ADHD after remediation.

This indicates (i) the importance of a comprehensive Conclusions


approach to the neuropsychological remediation of Our experimental study revealed the complex
children rather than the development of a separate structure of executive function disturbances in ADHD,
sphere, and (ii) the importance of remediation including neurodynamic deficits, difficulty sustaining
effectuated at the preschool age when there is still activity and attention, poor selectivity in decision making,
time before further schooling commences. The deficits in shifting from one executed activity to another,
comprehensive development of all higher mental poor planning, poor prognostic ability, problems recalling
functions in a preschooler will help him become more performance, and deficits in error correction. This is
successful in learning activities. Figure 5 illustrates the consistent with the published literature and complements
development of the spatial organization of movements it with important details.
and actions in a 4-year-old preschool child. Significant Comparisons of the syndrome of ADHD
results already appeared after a course that consisted between preschool and primary school children and
of 20 remediation sessions. The neuropsychological estimation of the dynamics of mental functioning after
assessment of children after a remediation course neuropsychological remediation in preschoolers showed
showed that the methods were effective for both the importance of assessment and remediation during
overcoming the problems in learning and attenuating the early preschool stage of development. The sooner a
the symptoms of ADHD (Glozman, Kurdyukova, & preschooler receives comprehensive neuropsychological
Shevchenko, 2013). assistance, the easier the learning process in school.

Figure 5. The copying of simple geometric shapes (circle, triangle, and square) by a 4-year-old child with ADHD before and after remediation.
460 Glozman and Shevchenko

Acknowledgement Koltsova, M. M. (1973). The child learns to speak. Moscow: Russia.


Korsakova, N. K., Mikadze, Y. V., & Balashova, E. Y. (2001).
This study was supported by the Russian Foundation Unsuccessful children: neuropsychological assessment of learning
for Humanities, project # 13-06-00570 and by the difficulties. Moscow: Russian Psychological Agency.
Kovalcikova, I. (2014). Executive functioning as a structural
Russian Scientific Foundation, project # 14-18-03253. component of ability to learn. Zmiani Rozwojowe w biegu zycia
konteksty I perspectywy (p. 33). Sklodowskiey w Lublinie: Insytut
Psychologii Uniwersytetu Marii Curie.
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Psychology & Neuroscience 2015 American Psychological Association
2015, Vol. 8, No. 3, 000 1983-3288/15/$12.00 http://dx.doi.org/10.1037/pne0000020

Correction to Glozman and Shevchenko (2014)

In the article Executive Function in Children With ADHD, by Janna M.


Glozman and Irina A. Shevchenko (Psychology & Neuroscience, 2014, Vol. 7,
No. 4, pp. 453 460, http://dx.doi.org/10.3922/j.psns.2014.4.04), the following
acknowledgment was inadvertently omitted from the author note:

This study was supported by the Russian Foundation for Humanities,


project # 13-06-00570 and by the Russian Scientific Foundation, project #
14-18-03253.

All versions of this article have been corrected.

http://dx.doi.org/10.1037/pne0000020